April 1999
News for members of the American Academy of Family Physicians
Y2K: You are not ready ...
The government will continue to sound the alarm, but the only alarm you really needed to hear rang out March 1. It's a 160-page congressional report that said that when it comes to year 2000 preparedness, the nation's health care system is in trouble.
In fact the document, which used information gathered during a series of Senate hearings in 1998, even singled out private practice physicians as being among the worst prepared for the so-called "millennium bug."
Most likely, you're not prepared.
"Many private doctors are using really old personal computers and really old programs," said David Kibbe, M.D., a former practicing FP who heads Future Health Care in Chapel Hill, N.C., a health care consulting firm. "The problem is not that these programs are so bad, but that practically all doctors have done zero, not a single thing, to prepare themselves."
Preparing yourself for the Y2K bug: That's exactly where Kibbe suggests you start. He points to one of his own personal computers, an IBM unit purchased in early 1998. Believe it or not, that machine would be incapable of normal function after Dec. 31 of this year, had Kibbe not recognized that fact and Þxed it.
So if you're interested in retaining and accessing data on your PC after Dec. 31 -- and just think for a moment about the functions you expect your personal computer to serve -- you might want to take similar action. The first step might be to contact the vendor who sold you the PC.
And when you can, Kibbe said, start working outward from that first proactive effort. He offered what he called "one big secret" -- many insurance companies aren't very prepared for Y2K either. There's a good chance you'll have a tougher time seeing money early next January. Kibbe suggested that unless you want staff layoffs until things clear up, you should have at least four months of overhead set aside.
"That's really the worst-case scenario, and it's also not what doctors are thinking about right now," Kibbe said. "But I remember when I was a practicing FP, I didn't keep any money in the bank."
Gregory Bergman, M.D., a Minster, Ohio, FP and member of the Academy's Committee on Communi-cations, echoed that theme.
"That's of importance to me: I don't want any cash flow problems," he said.
Bergman might be considered a role model in Y2K preparation. He's techno-savvy enough to have his own Web site and says he's just about ready to hang a "Y2K Compliant" banner in his waiting room. Just in case.
"Our patients haven't said much yet, but I expect a television blitz on how vulnerable the medical system is," he said.
Bergman said he's already finished upgrading his computer-based accounting software, and he recommends other FPs do the same right away, before software techs become so busy that you'll only get a "patch" to existing software.
Bergman said FPs should also send letters to supply vendors, asking for Y2K compliance details, in case problems do crop up Jan. 1 and a "paper trail is needed."
Bergman also suggested FPs have a monthlong stockpile of practice supplies, in case those same vendors don't come through on their compliance promises.
"But unfortunately, what's most important to us is that we don't lose track of cash," Bergman concluded. "Probably 90 percent of us are doing accounting on computer, so let's take care of it."
FPs interested in squashing the Y2K bug can keep current on the latest Y2K information at www.aafp.org/ fpnet/y2k. The Academy monograph concerning Y2K has been posted there since last fall, and the site has recently been updated to include information about the Health Care Financing Administration's requirements for using eight-digit date fields for claims submission (that requirement took effect April 5).
Phone numbers for regional HCFA offices are also included on the Web site, and Web site addresses for hardware and software vendors, plus special Y2K Web sites, are also listed.
The HCFA requirements document also is available by fax; see AAFP Express.
The American Medical Associa-tion also has Y2K information on its Web site. Check out http://www.ama-assn.org/not-mo/y2k/help.htm (it's on the members-only side).
Family physicians would be on front line during bioterrorist attack
Physicians would likely be the first to notice a bioterrorism attack, said organizers of a recent conference hosted by Johns Hopkins University.
The mid-February national meeting, held in Arlington, Va., put physicians ahead of the military or police in order of importance.
What's the rationale? The effects of a bioterrorist attack might not be evident until hours or days after the attack, and FPs and other primary care physicians would need to be able to recognize the attack and react in time.
Need bioterrorism knowledge?
Check out www.defenselink.mil/specials, a U.S. Department of Defense Web site. That's the recommendation of Col. John Powers, M.D., the FP consultant to the U.S. Army surgeon general. The colonel said the site has "the best information that has been verified."
The site is heavy on anthrax information since anthrax has long been a threat to the armed forces. It also includes links to sites covering many other biological agents.
ASPN seeks home within Academy
America's oldest practice-based primary care research network is seeking a new home within the AAFP.
The Denver-based Am-bulatory Sentinel Practice Network -- with about 700 family physicians and 50 other health professionals as members -- faces financial problems. It lacks reserves to cover about $400,000 in debts.
"The ASPN board met March 3 and unanimously agreed on restructuring ASPN and moving it into the AAFP," said Jerry Royer, M.D., of Sacramento, Calif., ASPN's part-time, interim executive director.
Royer, a family physician, recently was senior vice president and chief medical officer of Mercy Healthcare Sacramento and vice president for clinical quality at Catholic Healthcare West, a 48-hospital system.
The Academy has helped fund ASPN for seven years.
"The Academy has encouraged ASPN's growth over the years, and the AAFP Board will consider what might be the best way to preserve the central element of ASPN's mission -- practice-based research by family physicians," said AAFP EVP Robert Graham, M.D.
The ASPN board formed two subcommittees in January, one to monitor finances and one to search for an interim director, address repayment of the debts and guide ASPN's restructuring. Former ASPN Executive Director Paul Nutting, M.D., has resigned but is working on existing ASPN projects on contract as a senior research associate.
John Hickner, M.D., chair of the ASPN board of directors and family practice professor at Michigan State University in East Lansing, wrote ASPN members March 5.
"Stay with us during this time of reorganization," asked Hickner in the letter. "The budget issues will not affect completion of the current (research) projects. Please help us by participating fully in the current studies."
ASPN's current projects address topics such as treatment and referral of depressed patients and FPs' interventions with problem drinkers. Besides conducting its own studies, ASPN coordinates 20 local and regional family practice research networks with about 3,000 members.
Why keep ASPN? "Running a practice, especially in rural U.S.A., can consume all your life if you let it," said Michelle Petrofes, M.D., of Reedsport, Ore., an FP in ASPN. "ASPN is one part of making the work fit the ideal of learning from what we are doing, not continuing to do it without any thought as to why and whether we are getting better at it."
News from Headquarters
Online CME reporting considered success
Academy members are taking advantage of the AAFP Web site and reporting hours of CME in just a few minutes.
"When we started this service last year, we were unsure of the response we would receive," said Colleen Lawler, director of the AAFP Membership Division. "But the positive response has been overwhelming. One member told us he entered two years of CME in under 10 minutes."
M. Scott Doughty, M.D., of Zuni, N.M., wrote to thank the AAFP for offering online CME reporting.
"Thanks for the wonderful service," Doughty wrote in an e-mail. "This is my first re-election and your online reporting made it a snap!"
And you don't need to be computer-savvy to do it. Just enter the Academy's site at http://www.aafp.org/cme and select "Report Your CME Online." Then provide your AAFP ID number and your last name (you can also choose an optional password for the Web site if you'd like to provide additional security for your online account). After you've accessed the members-only section of the AAFP Web site, simply follow the directions for reporting your credit hours.
Academy calls for informatics papers, posters
The AAFP Committee on Scientific Program is seeking medical informatics papers for presentation Sept. 16 at the 1999 Scientific Assembly in Orlando, Fla. May 14 is the deadline for receipt of applications.
The submitted abstract should describe an original work, with relevance to family practice, in one of four categories: medically related Internet applications; electronic medical records; informatics for processes, outcomes, reporting and management; and patient education and communications. Selection criteria include originality of research, case study methodology, scientific merit, implementation, and effectiveness.
The author of the best paper in each category will receive an award of $500.
For more information, contact Vicky Binder at (800) 274-2237, Ext. 5264, or e-mail vbinder@aafp.org. The application form also can be downloaded from http://www.aafp.org/fpnet/mipres on the AAFP Web site.
Call for international posters
A call for international posters is being issued for presentation at the 1999 AAFP Scientific Assembly. Clinical or educational research that is relevant to family medicine and has been conducted outside the United States may qualify for submission. Registration fees to the Assembly will be waived for up to two principal authors of each approved poster. Applications must be received at the AAFP by May 7.
Look for more information at http://www.aafp.org/int/poster on the Academy's Web site, or write International Activities, AAFP, 8880 Ward Parkway, Kansas City, MO 64114, USA.
Products/Services
Now you can scan one place in FP Report -- this new department -- for products and services that might help you. Some of these items can be ordered by calling (800) 944-0000 unless otherwise noted; a shipping and handling charge may apply.
Free until May 1 -- get your copy of a CD-ROM featuring materials produced for AAFP's 1998 Annual Clinical Focus, "The Prevention and Management of Cardiovascular Disease." Item #R586; available for Windows '95 and '98 and Macintosh 7 or higher.
Prepare for the American Board of Family Practice board review. Sign up for one of AAFP's two 1999 Family Practice Board Review courses: May 9-15 in Greensboro, N.C., and June 6-12 in Seattle. Call AAFP Express for a registration form.
Discuss your favorite topic with other FPs. Five new e-mail lists will soon be available for discussions about tobacco, diabetes (topic of the 1999 Annual Clinical Focus), clinical procedures, quality improvement and rural health. Look for information on these mailing lists at http://www.aafp.org/whatsnew.xml under the "what's new" heading.
Get MEDLINE articles. If you conduct your own MEDLINE searches through PubMed, you now can designate AAFP's Herb L. Huffington Medical Library as your supplying library (the articles must be requested for teaching, scholarship or research, including research for patient care). For more information, access http://www.aafp.org/members/loandoc/ on AAFP's Web site.
Prepare for Match 2000. "Strolling Through the Match," a free guidebook on residency selection, is available from AAFP. Ask for item #R108, or access http://www.aafp.org/student/match/index.html.
Readers' Forum
Affirmative action
To the editor:
I am commenting on the Resident/Student News article "Attacks on Affirmative Action Threaten Medical School Diversity" (FP Report, February). Certainly the controversy concerning affirmative action is a difficult question.
I must say, however, that the statement "I think people clearly perceive the anti-affirmative action agitation as anti-minority agitation" by Dr. Herbert Nickens is a troubling statement and should not have been included in the article. I also doubt that the bullet points in the article are proven points.
Neither of my parents graduated from the eighth grade, but in no way did their lack of education add to my qualifications as a family practitioner of 45 years.
LEO R. GREEN, M.D.
Alton, Ill.Smoking letters
To the editor:
I am a third-year family medicine resident in Wichita, Kan., and am writing in reference to an article in the March FP Report. On the back page, there is mention of the fact that AAFP is in support of President Clinton's recommendation that Janet Reno, on behalf of the federal government, sue the tobacco companies to recover the Medicare costs associated with treating tobacco-related diseases. I want to strongly express my disgust for such support on behalf of the organization that represents me.
I am not in support of tobacco use and do agree that its use is destructive and costly. However, it is the individuals' choice to use tobacco and, therefore, their responsibility alone for the health consequences they suffer.
Everyone is aware of the dangers of tobacco use, and I do not believe that we should push the blame off on the tobacco companies. Our society is full of people trying to pass the buck and not take responsibility for their own actions, and this is another example of just that.
Where will this mentality lead us? Why not sue automakers for motor vehicle accident-related health dollars? And what about suing pharmaceutical companies for the costs of treatment related to adverse effects of their products? Oh, and let's sue fast-food chains for causing heart disease because of the high fat content of the majority of their foods. My point is that this will not end.
I adamantly oppose such action and want to register my complete disappointment in the stance that the AAFP has taken. I thought we were smarter than that.
DOUGLAS LEWIS, M.D.
Wichita, Kan.To the editor:
I oppose the idea of excusing people's personal responsibility for their decision to smoke. For 100 years people have admonished youth and adults that smoking is bad for your health.
Same with guns. If some drunk, angry, teenage gang member shoots someone, the problem is not addressed by suing the gun manufacturer.
If anyone shoots anyone unlawfully, there are plenty of laws to deal with that incident.
It is only logical and fair to take the same course with beer, wine and liquor producers and distributors.
LANCE E. MONROE, M.D.
Paragould, Ark.Hospitalists
To the editor:
Hospitalists (March FP Report) are an interesting topic -- seem to wonderfully improve efficiency. Where is efficiency in the Hippocratic Oath?
FRANK DENNEHY, M.D.
Wellsboro, Pa.
Other News
Magazine section features family physician perspectives on healthy living
Your patients may be interested in a special advertising section published in the April 1 Family Circle and the April McCall's magazines. The section, "Healthy Living," was developed in cooperation with the AAFP. Articles in the section cite FPs on issues such as managing your family's health care, living with allergies, dealing with menopause, eating heart-healthy food, helping children cope with diabetes and treating migraine headaches. The section was edited by Leigh McKinney, AAFP special projects editor, and Ronald Reynolds, M.D., of New Richmond, Ohio, who served as medical editor.
Want a free copy of each magazine for your reception area? Just call the Academy's order department at (800) 944-0000 and request item #R027.
Match trends show decline for second year
At press time, the National Resident Matching Program indicated that the 1999 fill rate for family practice residency programs was 2,697 positions filled out of the 3,265 positions offered. This is the second year the match program for family practice has experienced a decrease in positions filled.
In 1998, after six years of increases, the total fill rate was 85.5 percent, with 2,814 of the 3,293 available positions filled. The 1999 fill rate was 82.6 percent. The total number of family practice residency positions filled by U.S. seniors in 1999 trailed last year's match by 155. This year's numbers also showed a decrease in other categories of primary care in both total positions filled and those filled with U.S. seniors. The NRMP released the results March 20.
However, the trend is expected to be short-lived for a variety of reasons. "The number of third-year medical students who have joined the AAFP is significantly greater than the number of current fourth-year student members," said AAFP President Lanny Copeland, M.D., of Albany, Ga. "There is reason to believe that more of next year's fourth-year students will pursue family medicine."
Recently, medical students have received mixed messages about the stability of managed care and --with it -- primary care. "Students have been inundated with media reports predicting the end of managed care," said Copeland. "Stories are claiming that managed care is a fad and will fade, ending the need for primary care physicians. Research shows the opposite."
Students also are receiving the message from some professors that primary care soon will be handled by nurse practitioners and other midlevel providers. "Midlevel providers are unable to offer the same level of care as physicians; therefore, the implication is that the number of referrals to subspecialists will rise," he said. "Students are told that positions will be available in the subspecialties because that is where the patients will be. That's not necessarily so.
"Although the match numbers are somewhat down, there continues to be a need for well-trained, high-quality family physicians. Our members are constantly telling us how they are being overwhelmingly recruited for available jobs. Therefore, the AAFP will remain committed to ensuring that medical students receive as many opportunities as possible to fully understand what the practice of family medicine truly represents."
Downcoding?
Patients with three or more chronic medical problems typically have visits that could be coded as 99214.Your insurance carrier worries about upcoding, but you probably claim too little pay.
You may downcode every day and lose pay.
Codes for visits of established patients range from 99211 (minimal service) to 99215 (highly complex), and you may purposely aim low.
"Internists and pediatricians tend to charge for a much greater percentage of 99214 and 99215 visits," said Nancy Wilson Ashbach, M.D., of Denver. "FPs charge for a much higher percentage of 99212 and 99213 visits."
A member of the AAFP Commission on Health Care Services, Ashbach until recently worked for an insurance company and saw evidence of FPs' downcoding in a study of 700 Denver-area doctors.
She sees more evidence auditing family physicians' coding patterns as their consultant. They worry that if they code at the right level and don't document the visit perfectly, they'll be accused of fraud.
"They opt to see patients faster, code at a lower level and not take the chance that their coding might be challenged," said Ashbach.
Ashbach's advice: Use a preprinted form to document the components of each complicated visit. For examples of forms, see "Three Documentation Tools That Work" from the January 1998 Family Practice Management.
Hire QI/UR manager
Another commission member suggested hiring a quality improvement/ utilization review manager.
"You're busy seeing patients all day," said Charles "Shot" Rodgers, M.D., of Little Rock, Ark. "You may not have time to make sure systems are set up to prevent fraudulent claims. A good embezzler can take your code, upcode it and take a slice of what you were overpaid."
In Rodgers' practice of 30 physicians and three clinics, the QI/UR manager established systems to prevent fraud, unnecessary services and referrals to facilities in which the physician has a financial interest. In addition, the physicians and staff attend coding seminars regularly.
"Eight years ago, my average code was 99212, and now it's 99213 with some 99214s," said Rodgers. "I probably don't bill for as many 99215s as I should. But I'm coding better, and my documentation is better."
Track compliance
The Office of Inspector General estimates that improper payments under Medicare's fee-for-service system in fiscal year 1998 totaled $12.6 billion -- far less than the $20.3 billion estimate for 1997.
The OIG attributes the decline to the government's battle against Medicare fraud and to physicians' improved compliance with reimbursement rules.
To insulate your practice from a federal lawsuit, create a homegrown compliance program. Some resources:
- "Protect Your Practice With a Medicare and Medicaid Compliance Program" in the July-August 1998 Family Practice Management, at http://www.aafp.org/fpm.
- FP Assist, a network of consultants with profiles at http://www.aafp.org/fpassist.
- Medical Group Management Association, a Denver-based organization with resources for small group practices (online at http://www.mgma.com).
On the up-and-up
Earn more money for what you already do
For established patients with three or more chronic medical problems, if you take about 30 seconds longer for documentation, you'll raise your coding from 99213 to 99214.
That's a $15 difference.
"To me, taking a little extra time is well worth the $15," said Douglas Henley, M.D., of Fayetteville, N.C.
Henley, an AAFP past president, serves on the American Medical Association's Current Procedural Terminology Editorial Panel. It is advising the government on ways to streamline documentation guidelines for coding evaluation and management services.
But even under the 1997 documentation guidelines, said Henley, family doctors should typically code higher and receive more pay.
For example, when a child who had otitis media returns for an ear check, the visit would typically be coded as 99212. But after the ear exam, the mother or father might ask about a new problem the child has -- a rash, a sore big toe, whatever.
"If you document what you do to answer the 'Oh, by the way' question, the visit quickly becomes a 99213," said Henley.
That's an $11 difference.
"You aren't going to ignore the mother's question. So you take a little bit of extra history and do a little bit more examination, and you've met the test of a 99213," said Henley. "But most family doctors won't document that. They'll downcode themselves to a 99212 because to them, it's just a quick ear recheck, and that's the way they've always done it."
Perhaps they will change in 2000. New guidelines for coding evaluation and management services are expected to be implemented after next March. The 2000 guidelines will be simpler and easier to follow than the 1997 guidelines, said Henley.
Yes, but ...
Don't fall outside the bell-shaped curve with your federally funded patients. On the 5-level coding scale, code most of your services at level 3.
That's the advice of a family physician who was investigated by the federal government, she said, because of her high volume of federally funded patients.
Most of them used Medicare, Medicaid, and the Civilian Health and Medical Program for the Uniformed Services.
"If the majority of your practice is federally funded, that increases your risk of being audited," she said, asking not to be named.
Kent Moore, manager of reimbursement issues in the AAFP Socioeconomics Division, assisted her with a 1997 letter clarifying that time is not the determining factor in coding most evaluation and management services.
Moore recently said cases in which family physicians are charged with fraud are rare. "Still, this case highlights how important it is for family physicians to periodically review their coding patterns and make sure their documentation supports their codes," he said.
Family physicians in Medicare: Overwhelmed by red tape
Family physicians participating in Medicare are overwhelmed by red tape.
AAFP Board Chair Neil Brooks, M.D., of Rockville, Conn., took that message to Medicare's Practicing Physicians Advisory Council March 15 in Washington, D.C.
"Whether it is physician office laboratories, coding, reimbursement or even death, the Health Care Financing Administration probably has issued a rule about it," said Brooks. "The rules and paperwork have erected a very real and daunting challenge to simply treating the beneficiary."
HCFA's new Physician Regulatory Initiative Team is trying to identify the most burdensome Medicare rules. To help the team, 80 AAFP commission and committee members filled out a survey on Medicare hassles in January.
Brooks summarized what the survey respondents said:
- Medicare is the only program that continually brands physicians as guilty of fraud and abuse and creates a climate of fear of civil or criminal sanctions for honest mistakes. Doctors are surrounded by an "aura of criminality," as one respondent put it.
- Medicare is increasingly inflexible. Physicians feel they are losing control of medical decision making.
- Contradictory answers and delays by Medicare carriers make it hard to comply with regulations. Physicians fear that even asking for explanations of rules may lead to audits.
- Survey respondents most often named the following as problems: medical necessity rules, rules about use of notes written by students in teaching situations, and documentation of evaluation and management services.
Brooks suggested ways to alleviate the hassles and asked the advisory council to recommend those changes to HCFA. Brooks' testimony is at www.aafp.org/x1191.xml.
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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